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CO² filtration during pneumoperitoneum inflation and deflation in patients undergoing laparoscopy during the COVID-19 pandemic

ABSTRACT

The current Covid-19 pandemic has been the most discussed topic of the year, mostly about protection and ways to avoid dissemination of the virus. In the healthcare system, especially in the operating rooms, the viability of laparoscopic surgery was questioned, mostly because of the transmission through aerosol. This article tries to suggest a way to minimize risks of laparoscopic surgery, during this situation, by using electrostatic filters, a simple, effective and low cost alternative.

Keywords:
Coronavirus Infections; Surgery; Virology; Respiration, Artificial

RESUMO

A atual pandemia do Covid-19 tem sido o assunto mais discutido do ano de 2020, principalmente no que se refere a proteção e as formas de limitar a disseminação do vírus. No cenário hospitalar, mais especificamente no centro cirúrgico, a viabilidade da cirurgia laparoscópica foi questionada, em relação a transmissibilidade do vírus por aerossol. Este artigo sugere uma forma de minimizar os riscos em cirurgias laparoscópicas durante esse cenário, com o uso de filtros eletrostáticos de ventilação mecânica. Uma alternativa simples, eficaz e de baixo custo.

Palavras chave:
Infecções por Coronavírus; Cirurgia; Virologia; Respiração Artificial

COVID-19 is certainly the most discussed topic both by the scientific community and the lay media in the first semester of 202011 Correia MITD, Ramos RF, Bahten LCV. Os cirurgiões e a pandemia do COVID-19. Rev Col Bras Cir. 2020; 47:e20202536.. Among the many discussed topics, the potential transmission pathways and the adopted measures to avoid its dissemination dominate the discussions22 Lima DS, Leite Filho JAD, Gurgel MVSA, Aguiar Neto AF, Costa EFM, Maia Filho FXF, et al. Recomendações para cirurgia de emergência durante a pandemia do COVID-19. J Health Biol Sci. 2020;8(1):1-3..

Once the virus might be transmitted by aerosol, the viability of the laparoscopic procedures has been questioned, once it is known that other virus, as the B hepatitis, maybe in the environment air while insufflating and emptying the pneumoperitoneum33 Mintz Y, Arezzo A, Boni L, Chand M, Brodie R, Fingerhut A; the Technology Committee of the European Association for Endoscopic Surgery. A low cost, safe and effective method for smoke evacuation in laparoscopic surgery for suspected Coronavirus patients. Ann Surg. 2020;272(1):e7-e8.. The latter has led many medical societies to contraindicate the minimum invasive operations in the last months44 Chadi SA, Guidolin K, Caycedo-Marulanda A, Sharkway A, Spinelli A, Quereshy FA, et al. Current evidence for minimally invasive surgery during the COVID-19 pandemic and risk mitigation strategies: a narrative review. Ann Surg. 2020;272(2):e118-e124..

Bearing in mind the decreased morbidity and all the other advantages related to videolaparoscopy when compared to the conventional surgical approach, we have implemented safety protocols that allow us to carry out these procedures, guaranteeing patient safety as well as of those in the surgical room.

The electrostatic hygroscopic filters used for mechanical ventilation are of low cost and are easily available in the surgical room. This type of filter has an efficiency of 99.99% against bacteria and virus, such as those of B and C hepatitis; they have a diameter of 42nm and 30-60nm, respectively55 Wilkes AR, Benbough JE, Speight SE, Harmer M. The bacterial and viral filtration performance of breathing system filters. Anaesthesia. 2000;55(4):458-65.. The SARS-COV-2 has a bigger diameter, approximately 80nm, therefore, the same efficacy could be feasible. However, this requires further scientific confirmation33 Mintz Y, Arezzo A, Boni L, Chand M, Brodie R, Fingerhut A; the Technology Committee of the European Association for Endoscopic Surgery. A low cost, safe and effective method for smoke evacuation in laparoscopic surgery for suspected Coronavirus patients. Ann Surg. 2020;272(1):e7-e8..

The system is put together in a very easy and simple manner, by the interposition of the electrostatic filter and an intravenous line between the insufflation/draining system and the trocar, as shown in the below pictures.

Figure 1. Cutting of the line chamber.

Figure 1
Cutting of the line chamber.

Figure 2. The line chambre fits into the electrostatic filter.

Figure 2
The line chambre fits into the electrostatic filter.

Figure 3. The other line extremity is connected to the trocar.

Figure 3
The other line extremity is connected to the trocar.

Figure 4. The electrostatic filter connects the insufflator tube and the line.

Figure 4
The line chambre fits into the electrostatic filter.

There could be aerosol formation beyond the process of insufflation and drainage of the pneumoperitoneum66 Lancaster EM, Sosa JA, Sammann A, Pierce L, Shen W, Conte MC, et al. Rapid response of an Academic Surgical Department to the COVID-19 pandemic: implications for patients, surgeons and the Community. J Am Coll Surg. 2020;230(6):1064-73.. Therefore, we strongly recommend that not only strict care should be taken for the CO22 Lima DS, Leite Filho JAD, Gurgel MVSA, Aguiar Neto AF, Costa EFM, Maia Filho FXF, et al. Recomendações para cirurgia de emergência durante a pandemia do COVID-19. J Health Biol Sci. 2020;8(1):1-3. drainage, but also several other safety processes should be adopted during the COVID-19 pandemic11 Correia MITD, Ramos RF, Bahten LCV. Os cirurgiões e a pandemia do COVID-19. Rev Col Bras Cir. 2020; 47:e20202536..

The use of personal protective equipment, the decrease of the number of circulating personnel in the surgical room, in particular during intubation and extubation, as well as a low intraperitoneal pressure throughout the operation are among the extra care that should be taken66 Lancaster EM, Sosa JA, Sammann A, Pierce L, Shen W, Conte MC, et al. Rapid response of an Academic Surgical Department to the COVID-19 pandemic: implications for patients, surgeons and the Community. J Am Coll Surg. 2020;230(6):1064-73..

Considering that appendectomy is the most common urgent procedure carried out by videolaparoscopy, we recommend the videoassisted technique whose effectivity and safety has been well demonstrated77 Lima GJS, Silva AL, Castro EG, Abras GM, Pires LJS, Leite RFG. Efetividade e segurança da apendicectomia videoassistida em porta única transumbilical em adolescentes e adultos. Rev Col Bras Cir. 2008;35(4):244-51.. Under this technique there is less pneumoperitoneum exposition time. Furthermore, there is no need for the use of the electrocautery which could also be responsible for aerosol formation88 Lima GJS, Silva AL, Leite RFGL, Abras GM, Castro EG, Pires LJS. Apendicectomia videoassistida por acesso único transumbilical comparada à via laparoscópica e laparotômica na apendicite aguda. Arq Bras Cir Dig. 2012;25(1):2-8..

The CO22 Lima DS, Leite Filho JAD, Gurgel MVSA, Aguiar Neto AF, Costa EFM, Maia Filho FXF, et al. Recomendações para cirurgia de emergência durante a pandemia do COVID-19. J Health Biol Sci. 2020;8(1):1-3. filtration during the pneumoperitoneum insufflation and drainage, along all the other measures, has added extra care to guarantee safety during the pandemic. These are easy and low cost attitudes that minimize the risks of videolaparoscopy.

REFERENCES

  • 1
    Correia MITD, Ramos RF, Bahten LCV. Os cirurgiões e a pandemia do COVID-19. Rev Col Bras Cir. 2020; 47:e20202536.
  • 2
    Lima DS, Leite Filho JAD, Gurgel MVSA, Aguiar Neto AF, Costa EFM, Maia Filho FXF, et al. Recomendações para cirurgia de emergência durante a pandemia do COVID-19. J Health Biol Sci. 2020;8(1):1-3.
  • 3
    Mintz Y, Arezzo A, Boni L, Chand M, Brodie R, Fingerhut A; the Technology Committee of the European Association for Endoscopic Surgery. A low cost, safe and effective method for smoke evacuation in laparoscopic surgery for suspected Coronavirus patients. Ann Surg. 2020;272(1):e7-e8.
  • 4
    Chadi SA, Guidolin K, Caycedo-Marulanda A, Sharkway A, Spinelli A, Quereshy FA, et al. Current evidence for minimally invasive surgery during the COVID-19 pandemic and risk mitigation strategies: a narrative review. Ann Surg. 2020;272(2):e118-e124.
  • 5
    Wilkes AR, Benbough JE, Speight SE, Harmer M. The bacterial and viral filtration performance of breathing system filters. Anaesthesia. 2000;55(4):458-65.
  • 6
    Lancaster EM, Sosa JA, Sammann A, Pierce L, Shen W, Conte MC, et al. Rapid response of an Academic Surgical Department to the COVID-19 pandemic: implications for patients, surgeons and the Community. J Am Coll Surg. 2020;230(6):1064-73.
  • 7
    Lima GJS, Silva AL, Castro EG, Abras GM, Pires LJS, Leite RFG. Efetividade e segurança da apendicectomia videoassistida em porta única transumbilical em adolescentes e adultos. Rev Col Bras Cir. 2008;35(4):244-51.
  • 8
    Lima GJS, Silva AL, Leite RFGL, Abras GM, Castro EG, Pires LJS. Apendicectomia videoassistida por acesso único transumbilical comparada à via laparoscópica e laparotômica na apendicite aguda. Arq Bras Cir Dig. 2012;25(1):2-8.
  • Erratum

    The article "CO2 filtration during pneumoperitoneum inflation and deflation in patients undergoing laparoscopy during the COVID-19 pandemic", DOI number: 10.1590/0100-6991e-20202632, published in the Journal of the Brazilian College of Surgeons. 48:e20202632:
    Where it is:
    "Gustavo Munayer Abras, ACBC-MG1,2; Thiago Augustus Blasco e Silva, ACBC-MG3,4; Luiz Felipe Pimenta Nogueira de Souza Lima5; William Dias Belangero5; Mauro Vidigal de Rezende Lopes6."
    It should be:
    "Gustavo Munayer Abras, ACBC-MG1,2; Thiago Augustus Blasco e Silva, ACBC-MG3,4; Luiz Felipe Pimenta Nogueira de Souza Lima5; Mauro Vidigal de Rezende Lopes6."
  • Funding source:

    none.

Publication Dates

  • Publication in this collection
    22 Jan 2021
  • Date of issue
    2021

History

  • Received
    26 May 2020
  • Accepted
    01 June 2020
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